Moving Mountains in Mozambique

On Chronic* Diarrhea: Part III

The giardia has officially left the building. Four stools samples produced negative results – no parasites, no pathogens, and no noticeable bacterial overgrowths (such as H. Pylori).

News Flash:

Just because the giardia left doesn’t mean the building is stable. The integrity of its internal structure has come under question. “This is called postinfectious IBS, and people who suffer from it may have an ongoing very mild inflammation of the gut” (Gibson and Shepherd, The Complete Low-FODMAP Diet). Endoscopic probes in February – after three months of parasitic inhabitation – noted systemic inflammation of the gastrointestinal tract. While the inflamer has been extinguished, his wreckage smolders on. Two weeks of medical appointments in Maputo to receive the information presented in this “Update” translated to two weeks of consuming food in restaurants translated to two weeks of diarrhea.

True Life: I have IBS.

The scene opens with the doctor at his desk reviewing a patient file. The patient, a tall, thin American waits patiently in the chair opposite the doctor, as patients do. It seems the patient has asked a question. He is concerned. Why can’t he just be normal like the other kids? Why can’t I go back to the way I was? He awaits the doctor’s response. The latter ponders his notes a moment longer before responding. “This is what we call the IBS.” The camera focuses on the doctor’s face. “This is the new you.” The camera swivels around to lock onto the patient’s horrified face. Letters flash across the bottom of his screen. “True Life: Living with IBS.” Oh wait, no the expression on his face isn’t horror; he just shit himself again.

Insider Exclusive: I’ve been drugged.

The gut has a profound impact on the brain and individuals with IBS often experience symptoms of anxiety (the majority of neurotransmitters like GABA, dopamine, serotonin, and more actually reside in the gut). To combat this, the doctors gave me Amitriptyline. Amitriptyline is one of several tricyclic antidepressants commonly prescribed for patients suffering from IBS (about one in five people worldwide suffers from IBS). The dosage was low enough that I should not have noticed it at all. The mechanism of the drug, a serotonin-norepinephrine reuptake inhibitor, would only produce effects perhaps two weeks down the line. The first dose, however, floored me. I took the pill Tuesday night. Wednesday I was only awake for a period of about two hours, during which time I felt as if I ate the lion’s share of a hash brownie. My hotel room spun. I wobbled into the hotel bathroom for another round of diarrhea before crawling back into my bed. I felt sedated; I was sedated.

Hormonal medications are not for me, I decided after this incident. If I am going to beat this thing, I’m going to do it naturally. The curse of twentieth century medicine is that we all think we can take a pill to recover from whatever ails us. Sprained ankle – take some ibuprofen. Common cold – load up on Vitamin C supplements. Daddy issues – try some Prozac. Atherosclerosis – try this statin drug. Wherever there is an ill, there is someone with a pill designed to treat the symptoms. In my postinfectious IBS case, the doctor wrote off a prescription for an antidepressant, a pro-biotic (not available in Mozambique), and several anti-spasmodic drugs to treat symptoms as they occur. But what about the overall systemic inflammation? How does inhibiting my body’s ability to absorb serotonin repair the lining of my small intestine? It doesn’t, but it sure does make you feel better. Or rather, it sure does make you feel less.

Drugs have their time and their place. Without antibiotic drugs like metronidazole, a parasite would still be leeching weight from my ribcage until it looked like a xylophone. I understand the assumption that reducing mental anxiety can reduce irritation in the gut – everyone has experienced the sensation of butterflies in their stomachs before a nerve-racking event. Emotions have a home in the gut. Inhibiting the visceral experience of emotions, however, will not resolve the underlying damage to my intestines. Moreover, there are effective ways to manage stress and anxiety that do not depend upon sedation. I have only just discovered my gut; I don’t want to numb him from my life just yet. Instead, I spend fifteen minutes every morning meditating, honing in on the sensation in my navel region. Whereas our skin has many pain receptors so that our brains can identify the exact source of pain (like the bee that stung my toe two days ago), the abdomen only has general pain receptors. This means that our brains only recognize an occurrence in the abdomen as a whole; the exact source cannot be located. Our utmost extremities are more sensitive than the core of our bodies – perhaps that explains why it’s easier to spend an hour on Facebook analyzing the lives of others rather than reflecting upon our own behavior. Perhaps that’s why we crave the touch of another person more than our own hands.

Since the beginning of this process, I have noticed a difference in my connection with my abdomen. He talks to me. He speaks in a language known as borborygmi – “audible noises and rumblings from the abdomen” (Gibson and Shepherd). Long periods without eating make him talk. Eating too much makes him talk. Both of these situations are aggravated if I lay down or invert my torso (no handstands for me). Certain foods make him talk more than other foods (see the explanation of FODMAPs in the first post of this series). Communicating with him is an ongoing process, a feedback loop that I record every day in a journal. I left Maputo eight days ago and have consumed slow-cooked meat broths with vegetables everyday since. This makes my abdomen happy. Slowly, I hope, he will come to accept more and more food items as the intestinal lining heals and the diversity of my gut flora expands. The important part of any healthy relationship is communication. Our bodies are always speaking to us – I guess mine just had to yell before I noticed.

Now, however, I fret that I pay too much attention to my metabolism. More important things are happening in the world right now than the emulsification of fats in my duodenum (such as Mozambique’s billion dollar hidden debt crisis). Striking a balance is key. During the month of March, I spent the majority of my free time collecting research on IBS and gut health. For two weeks in Maputo, I binged on the Internet: morning and evening I scoured the web and downloaded everything I could find on postinfectious recovery. Do not doubt that the gut-brain axis affects our conscious focus and emotional well-being. Shepherd writes, “If you require a special diet, it can start to dictate your thoughts, and some people cope better with this than others” (hence the prescription for antidepressants). Truly, my thoughts do not stray far from breakfast, lunch, and dinner these days. But I left Maputo feeling empowered: I know now that my reaction to foods is functional rather than the result of a parasite and, furthermore, I amassed a multitude of research on treating IBS from a wide variety of sources. For the next eight weeks I will apply what I have learned and observe the results. I am my own experiment, with a built-in borborygmic feedback loop and a healthy roommate to serve as a control specimen when I test out new foods. Not surprisingly, as I calmed the post-Maputo flare-up during the last week with meat broths, my stools have solidified and so have my priorities. Health will always be at the forefront of my concerns. That being said, self-teaching biology, anatomy, and nutrition during my last eight months of Peace Corps service seems like a waste of the opportunities at my disposal. Teaching English, speaking Portuguese, cooking, exercising, and writing – five activities that promote self-improvement without disassociating me from my current circumstances. I write them here more for my own benefit – a typed reminder – than for yours.

When my poops lose their substance, so do my priorities. But when your poops are solid, so are your goals (my abdomen told me that).

They talk of short-lived pleasure—be it so—
Pain dies as quickly: stern, hard-featured pain
Expires, and lets her weary prisoner go.
The fiercest agonies have shortest reign;
And after dreams of horror, comes again
The welcome morning with its rays of peace.
Oblivion, softly wiping out the stain,
Makes the strong secret pangs of shame to cease:
Remorse is virtue’s root; its fair increase
Are fruits of innocence and blessedness:
Thus joy, o’erborne and bound, doth still release
His young limbs from the chains that round him press.
Weep not that the world changes—did it keep
A stable changeless state, ’twere cause indeed to weep.

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Rudyard Kipling: “Words are, of course, the most powerful drug used by mankind.” My words are my words and mine alone. The views herein expressed do not reflect those of the Peace Corps, the Fulbright Program, the U.S. Department of State, or any of its partner organizations.